<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Nametext')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-nametext" data-rule="required" class="form-control" name="row[nametext]" type="text" value="{$row.nametext|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Descriptioncontent')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-descriptioncontent" data-rule="required" class="form-control editor" rows="5" name="row[descriptioncontent]" cols="50">{$row.descriptioncontent|htmlentities}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Coverpicimage')}:</label>
        <div class="col-xs-12 col-sm-8">
            <div class="input-group">
                <input id="c-coverpicimage" data-rule="" class="form-control" size="50" name="row[coverpicimage]" type="text" value="{$row.coverpicimage|htmlentities}">
                <div class="input-group-addon no-border no-padding">
                    <span><button type="button" id="faupload-coverpicimage" class="btn btn-danger faupload" data-input-id="c-coverpicimage" data-mimetype="image/gif,image/jpeg,image/png,image/jpg,image/bmp" data-multiple="false" data-preview-id="p-coverpicimage"><i class="fa fa-upload"></i> {:__('Upload')}</button></span>
                    <span><button type="button" id="fachoose-coverpicimage" class="btn btn-primary fachoose" data-input-id="c-coverpicimage" data-mimetype="image/*" data-multiple="false"><i class="fa fa-list"></i> {:__('Choose')}</button></span>
                </div>
                <span class="msg-box n-right" for="c-coverpicimage"></span>
            </div>
            <ul class="row list-inline faupload-preview" id="p-coverpicimage"></ul>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pricenumber')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pricenumber" data-rule="required" class="form-control" name="row[pricenumber]" type="number" value="{$row.pricenumber|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Clinic_ids')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-clinic_ids" data-rule="" data-source="coupons/clinic/index" data-multiple="true" class="form-control selectpage" name="row[clinic_ids]" type="text" value="{$row.clinic_ids|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Group_ids')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-group_ids" data-rule="required" data-source="user/group/index" data-multiple="true" class="form-control selectpage" name="row[group_ids]" type="text" value="{$row.group_ids|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Weigh')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-weigh" data-rule="required" class="form-control" name="row[weigh]" type="number" value="{$row.weigh|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Effective')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-effective" data-rule="required" class="form-control" name="row[effective]" type="text" value="{$row.effective|htmlentities}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>